Bullets and Bacilli: The Spanish-American War and Military Medicine (review)

Of all of the United States' "forgotten wars," perhaps none is more forgotten than the Spanish-American War. Fought during the summer months of 1898, it had few combat fatalities and many geopolitical victories, and since then has been overlooked by many historians, including medical historians. Vincent Cirillo remedies this deficit and demonstrates that, as the first war fought after the introduction of the germ theory and of X rays, this war had a far greater impact on military medicine than its short duration would have indicated.

Cirillo describes the political situation that led to hostilities, and the military situation that had to deal with them. Noting that the navy had few sanitary issues and short battle engagements, he focuses instead on the army's longer battles in the Caribbean, which, from the medical perspective, were a disaster. Only 345 soldiers died in combat, but 2,565—almost 66 percent of all war-related deaths—died of disease, mostly typhoid fever. The sheer number of deaths from disease was a debacle that the army could not hide and had to address.

Deaths from bullets were fewer than deaths from bacilli because of improved military surgical techniques and the introduction of radiology. Army surgeons had adopted a conservative, expectant attitude toward gunshot wounds, and were less likely to amputate limbs than were their counterparts in the Civil War. Aseptic technique also saved lives. Radiology helped find lodged bullets or assess wound damage, but X-ray equipment was on land and on three ships; their bulk and electrical needs meant there were no mobile X-ray units during the war.

The germ theory's scientific foundation for civilian sanitary policies had become reasonably well established by the start of the war, but, as Cirillo argues, the army's culture prevented these advancements from being incorporated into military medicine. The army had only a small Medical Department in 1898: most of the war's medical personnel were volunteer "contract surgeons," who had no authority outside the Medical Department; no matter their own rank, they could only advise, but not order, line officers. The army wanted them to tend the wounded and cure the sick, but not to impose preventive hygienic measures in the camps. This disjunction between knowledge and authority led to the typhoid epidemics.

After the war, the army established the Dodge Commission to examine why so many soldiers had died and to recommend measures to improve military hygiene and medicine. The commission concluded that the army had failed for reasons beyond its control, and recommended that the army have more commissioned medical officers, a reserve corps of trained female nurses, and stockpiles of nonperishable medical supplies. All of these recommendations soon became standard practice. In 1905, West Point introduced a course in military hygiene, and in 1911 the army mandated antityphoid immunization.

In addition, Surgeon General George Sternberg established three boards to study typhoid fever, yellow fever, and tropical diseases. Walter Reed and Leonard Wood and their colleagues had recognized the healthy typhoid carrier and the mosquito vector for yellow fever and dengue fever. The Ashford Commission's success in hookworm control became the model for the 1909 Rockefeller Sanitary Commission. Through the army's reforms of its Medical Department and its scientific work, military medicine became an accepted medical specialty. Changes in military culture, especially the adoption of hygienic practices and preventive medicine and the granting of authority to medical personnel, meant that the army would have fewer noncombat deaths in World War I.

Cirillo has meticulously documented his well-constructed argument, especially the army's realization that it had to adopt preventive medicine. The book should serve well not only medical historians but also military and American historians.